2. Common IO Myths BIG Insertion is extremely painful The BIG insertion is very rapid and no more painful than an IV line. In Conscious patients it is recommended to add Lidocaine to the initial solution. 85% of the patients are unconscious.

3. BIG Insertion Is a Difficult Procedure To Perform The BIG insertion can be done after a short training session. After learning the location differences between Adults and Pediatrics you will be able to insert the BIG with no effort.

4. BIG Infusion Can Be Done Only In Red Bone Marrow Researches in various animal models showed that drugs are being delivered to center circulation in both Red and Yellow Bone Marrow.

5. Anatomy

6. Indications IO is the most appropriate option for vascular access when IV is difficult or impossible. Experience with the BIG: Cardiac Arrest, all kinds of Shock, Dehydration, Respiratory failure, Trauma, O.D Burns, Seizures, Diabetic Emergencies…

7. Indications MCI Conventional threat

9. Indications MCI Unconventional threat

10. How to use the AdultB.I.G. device?

11. Location (1) Place a rolled towel under knee with the foot facing outward. Find the outset point : Tibial Tuberosity- A rounded protrusion right down the patella. *Locate the Tuberosity and feel it on your leg.

12. Location (2) From the Tibial Tuberosity Go approx. 2 cm (1 inch) to the inner part of the leg to find a flat site. This is the Tibial Plateau.

13. Location (3) From Tibial plateau Go UP approx. 1cm (0.5 inch) toward the patella. *You are looking for the thinnest portion of the cortex.

14. Location (4) Summary (adult patient): From Tibial Tuberosity Go approx. 2 cm (1 inch) IN (inner leg). And approx. 1 cm (0.5 inch) UP (toward patella). *Try to find the insertion site on your leg.

15. Positioning

16. With one hand holding firmly, Position the BIG At a 90 degree angel to the surface of the skin. *use aseptic technique throughout

17. Safety latch With one hand holding the BIG firmly, Pull out the safety latch by squeezing its two sides together. (The safety latch should be at the farthest point of the leg). *Do not discard, it will later be used.

18. Triggering While continuing to hold the bottom part firmly against the leg, Place 2 fingers of your other hand under the ‘winged portion’ and the palm of that hand on the top. Leanining on the device with straight elbows will activate the B.I.G. Trigger the BIG by gently pressing down. Note: Extra force is not required.

19. Stylet trocar Pull out the stylet Trocar. Only Cannula remains in the bone.

20. Fixation The safety latch provides additional stability.

21. Aspiration Bone marrow can be aspirated into a syringe for laboratory sampling. Note: Lack of bone marrow does not mean the IO is improperly placed.

22. Flushing Flushing 10-20cc (5-10cc in Pediatrics) of saline is recommended before the injection of fluids or drugs. *In conscious patients- consider local anesthesia prior to administrating fluids.

23. Administration Now you can administrate fluids and drugs as required. Optional : Connect a stopcock to the cannula and than use a standard I.V set.

24. Avoid this…